Is It Right for You?

Almost everyone should be able to get health coverage. The question is, which plan is right for you and your family?

This page looks at the different ways you might qualify for Medicaid based on your disability.

Just because you have a disability does not mean that you qualify for disability-based Medicaid. You may qualify for Medicaid through different rules, or you may not qualify for Medicaid at all, depending on your situation.

Ways to Get Disability-Based Medicaid

There are different ways to get disability-based Medicaid in Georgia that support people in different situations and have their own eligibility requirements.

SSI-Linked Medicaid

The most common way of getting disability-based Medicaid is getting it automatically with Supplemental Security Income (SSI) benefits. If you already get SSI benefits, you have Medicaid coverage.

To qualify for SSI, you must:

• Have a disability that meets Social Security's definition of disability.
• Be a U.S. citizen or qualified alien.
• Have countable resources at or below the SSI program's limit of $2,000 ($3,000 for a couple).
  • Note: If your disability began before you turned 26, you can open an ABLE account and save up to $100,000 without it being counted by SSI. Learn more about ABLE accounts.
• Have countable income below the income limit for your living situation ($967 per month for most people who live alone).

Learn more about SSI and see if you qualify.

Note: If you used to get SSI benefits when you were under 18, but then started getting Childhood Disability Benefits (CDB) when you turned 18 and stopped qualifying for SSI, you can usually keep your Medicaid coverage.

When Social Security counts your income, it’s not the same as your real, full income. Almost all of your unearned income, like Social Security Disability Insurance (SSDI), is counted, but less than half of your earned income is counted. For example, if you make $2,000 per month at a job and have no other income, that’s only $957.50 in countable monthly income. Learn more about how SSI counts your income.

Use this tool to see your countable income:

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
Your Monthly Countable Income
Your Annual Countable Income
	$15,650
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

Add to favorites

Add to favoritesAdd to favoritesOne of my favorites

SSI's 1619(b) Rule

If your SSI benefits go to zero because you go back to work, an SSI rule called 1619(b) lets you keep your Medicaid coverage if you:

• Were eligible for SSI benefits for at least one month
• Need Medicaid coverage to keep working
• Still meet all the other SSI requirements, such as being disabled and having resources below $2,000, and
• Make less than $38,308 in gross income per year.
  • If your earnings are over this limit and you have high medical expenses, you might still qualify for 1619(b). Ask your Work Incentive Counselor and your local Social Security office about the 1619(b) Individualized Earnings Threshold.

For additional information, check out Social Security’s webpage on 1619(b) or talk to a benefits expert.

Medicaid Waiver Programs

Medicaid waiver programs are for people who need higher levels of care to live in their own home or apartment in the community instead of moving into a facility. If you have a waiver, you get regular disability-based Medicaid coverage, plus extra services you need to live in the community.

To qualify for a waiver program, you must:

• Need a level of care normally provided by a hospital, nursing home, or other care facility.
• Have resources that are $2,000 or less if you are single ($3,000 or less for couples).
• Have gross income at or below $2,901 or less a month.

Note: Waiver programs often have waiting lists, so even if you are eligible, you may not get Medicaid coverage right away.

Learn more about Medicaid waiver programs.

Medicaid with a spenddown

Medicaid with a spenddown is a way for people with disabilities and seniors who have low resources ($2,000 or less for an individual, $4,000 or less for a couple) to get Medicaid if their income is too high to qualify for SSI. However, unlike other ways of getting Medicaid, Medicaid with a spenddown is very expensive, especially if you have a lot of medical needs.

Medicaid with a spenddown, also called the Medically Needy program, means that you must spend some of your own money—often hundreds of dollars, depending on your income—on medical bills each month before you can get Medicaid coverage that month. For example, if your monthly countable income is $1,167, you'll have to spend $850 per month to get Medicaid coverage. We explain how Medicaid with a spenddown works, and how much you have to pay, later in the article.

You should only sign up for Medicaid with a spenddown if you have no other health coverage options. Before you sign up, make sure you consider all other types of health coverage, including:

• Employer-sponsored coverage, if you can get it through your job or a family member's job.
• Medicare, if you qualify.
  • If you have Medicare, you may qualify for a Medicare Savings Plan (MSP), which would help pay your Medicare expenses.
• An individual plan from Georgia Access.
  • Buying an individual health plan may be more affordable than Medicaid with a spenddown, especially because the government may help you pay for it with tax subsidies.

If you don’t qualify for any of these disability-based Medicaid programs, you may qualify for Medicaid through Georgia Pathways to Coverage, which has no resource limit and does not require you to have a disability. Note: If you are eligible for any disability-based Medicaid programs, or if you have Medicare and qualify for a Medicare Savings Plan, you cannot get Pathways.

To qualify for Pathways, your family's income must be at or below 100% of the Federal Poverty Guidelines (FPG) ($1,305 per month for an individual in 2025, $2,679 for a family of four). Children and pregnant women can have higher incomes.

Try the tool below to see if you may qualify for Pathways Medicaid based on your family's income.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$15,650
	$5,500
	$15,060
	$5,380
	252
Georgia Pathways to Coverage Medicaid (100% FPG)
PeachCare for Kids (252% FPG)
Subsidized private plans, reduced fees (100% FPG - 250% FPG)
	to
Subsidized private plans (no upper income limit)	--
If your family's income is within the limits for a program, you may qualify if you meet other program rules. Notes: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). Not all Medicaid categories are included here. For private plans with subsidies, your monthly premium amount depends on your income.

Add to favorites

Add to favoritesAdd to favoritesOne of my favorites

Learn more in DB101's Georgia Pathways to Coverage article.

Medicaid, Medicare, and Private Health Coverage

Here we will look at what signing up for Medicaid might mean if you also have or want Medicare or private coverage.

Medicaid and Medicare

If you are a senior or the Social Security Administration says you have a disability, you may be able to get Medicaid and Medicare at the same time.

There are significant advantages to this. Most importantly, if you have both:

• Medicaid may pay your Part B premium (and your Part A premium, if you have one) through a Medicare Savings Plan (MSP). Depending on your MSP, it may also pay your Medicare deductibles, co-insurance, and copayments.
• You will automatically be enrolled in a Part D benchmark plan and automatically qualify for the Part D Low Income Subsidy. The Low Income Subsidy means you may not have to pay a premium for your Part D or any deductibles. All you would pay for prescription drugs are Part D’s copayments, which range from $1.60 to $12.15.
• Medicaid covers many more services than Medicare, so by having both you’ll have better health care coverage than you would by enrolling in just one or the other.

Contact the Georgia State Health Insurance Assistance Program (SHIP) if you have questions about how your Medicaid and Medicare benefits work together. To learn more, read DB101’s Medicare article.

Medicaid and Employer-Sponsored Health Coverage

If you qualify for Medicaid, it will usually be your best choice, even if your employer offers health insurance. That’s because Medicaid has no monthly premium and the copayments for services are usually much lower than copayments required by employer-sponsored plans. Also, Medicaid may cover some services that your employer-sponsored coverage does not pay for.

However, there are a couple of advantages to having both Medicaid and employer-sponsored coverage at the same time:

• Private insurance may cover some benefits that Medicaid doesn’t or the other way around.
• Private coverage may let you choose from more doctors.

If you qualify for Medicaid and you can get health coverage through your job, Medicaid may pay your employer-sponsored coverage premiums through the Health Insurance Premium Payment (HIPP) program, if doing so would save money for Medicaid. In that case, you could have regular Medicaid coverage and private health coverage at the same time. HIPP does not pay your deductible or copayments. Learn more about HIPP.

Medicaid and Individual Plans

If you are eligible for Medicaid, then you do not qualify for government help to pay for a private insurance plan. If you qualify for Medicaid, it will always be a better option for you than paying for an individual plan.

Exception: If you have Medicaid with a spenddown, an individual plan may be more affordable than your Medicaid coverage. And if your income is more than 100% of the Federal Poverty Guidelines (FPG), the government may help you pay for your plan. Learn more about buying private health coverage.